How to File an Appeal

It is Edenbridge PACE of West Baltimore’s policy to provide all medically necessary services covered by Medicare and Medicaid, and other services determined necessary by the IDT to improve or maintain participants’ overall health status. Edenbridge PACE of West Baltimore, is committed to ensuring that a participant, a participant’s representative or a treating provider has the right to appeal Edenbridge PACE of West Baltimore program’s decision to deny, defer, terminate or reduce a particular care-related service or its decision not to pay for a service received by a participant. In addition, if Edenbridge PACE of West Baltimore fails to provide the participant/designated representative with timely notice of the resolution to service determination request or does not furnish the services required by the participant’s revised plan of care, this failure constitutes an adverse decision; and the request must be automatically processed as an appeal.

Definitions:

An appeal is defined as a participant’s action taken with respect to the PACE organization’s noncoverage of, or nonpayment for, a service including denials, reductions or termination of services. A request to initiate, modify or continue a service must first be processed as a service determination request before Edenbridge PACE of West Baltimore can process an appeal.
An appeal may be filed verbally, either in person or by telephone or in writing. The appeals process may take one of two following forms:

• A standard appeal means a standard review process for response to, and resolution of, appeals as expeditiously as the participant’s health requires, but no later than 30 calendar days after the PACE organization receives an appeal.
• An expedited appeal occurs when a participant believes that his or her life, health or ability to regain or maintain maximum functions would be seriously jeopardized, absent provision of the service in dispute. Edenbridge PACE of West Baltimore will respond to the appeal as expeditiously as the participant’s health condition requires, but no later than 72 hours after it receives the appeal. The 72-hour timeframe may be extended by up to 14 calendar days for either of the following reasons:

1. The participant requests the extension.
2. Edenbridge PACE of West Baltimore will provide justification to the State Administering Agency the need for additional information and how the delay is in the interest of the participant.

Disputed health care service means any health care service eligible for payment under the enrolled participant’s contract with Edenbridge PACE of West Baltimore that has been denied, modified or delayed by a decision of Edenbridge PACE of West Baltimore in whole or in part due to the finding that the service is not necessary.

Necessary or Necessity means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.

Representative means a person who is acting on behalf of or assisting a participant, and may include, but is not limited to, a family member, a friend, a Edenbridge PACE of West Baltimore employee, or a person legally identified as Power of Attorney for Health Care/Advanced Directive, Conservator, Guardian, etc.

Edenbridge PACE of West Baltimore will provide you with timely preparation and processing of a denial of coverage or payment in writing; upon receipt of a service determination request, we will make a decision and notify you as expeditiously as your condition requires, but no later than 3 calendar days after the date we receive your request. If Edenbridge PACE of West Baltimore denies your request for a service, for payment of a service, terminates or reduces your service, or if you are involuntarily disenrolled from Edenbridge PACE of West Baltimore, you have the right to file an appeal. You will be given written information on how to file an appeal at enrollment, at least annually thereafter, and whenever we deny a request for services or payment. You or your family or caregiver may request information on our appeal process at any time.

If you file an appeal, you will continue to receive the health care services the same as before you filed the appeal. However, if the appeal does not favor you, then you may be responsible for payment of the services in question. If you are not receiving the services for which you filed the appeal, and the appeal does result in a determination that favors you, then Edenbridge PACE of West Baltimore will provide the disputed service as expeditiously as your health condition requires. Edenbridge PACE of West Baltimore employees will not discuss your appeal with anyone not involved in investigating your appeal.

If Edenbridge PACE of West Baltimore denies either a service you requested or payment for a service you received, you may file an appeal either verbally or in writing. You or your family or caregiver may file an appeal by telephoning us between the hours of 8:00 a.m. –
5:00 p.m., by indicating your desire to file an appeal in person at the PACE Center, or by sending a letter to Edenbridge PACE of West Baltimore at the following address:

Edenbridge PACE of West Baltimore
3201 A Tioga Parkway
Baltimore, MD 21215

Center Manager, Social Worker or any interdisciplinary team member (IDT) at (toll free) 833-722-3225, or TTY for Hearing impaired at 443-961-0801.

In addition to our Edenbridge PACE of West Baltimore Program Director, a person not involved in the initial decision will evaluate your appeal. This person will be both impartial and appropriately qualified to make a decision. You or your family or caregiver may present or submit relevant facts and/or evidence for review, either in person or in writing to us, for consideration during the appeal process.

We will respond to and resolve your appeal as expeditiously as your health condition requires but no later than 30 calendar days after receiving your request for an appeal. If you believe that your life, health or ability to regain maximum function would be seriously jeopardized if the disputed service is not provided, you may request an expedited appeal. The Edenbridge PACE of West Baltimore Program Director and the objective third party will review your case immediately and respond back to you within 72 hours. If you request an extension or we need more time to review the case and your health is not in danger, we may require up to 14 calendar days to review your expedited appeal.

THE DECISION ON YOUR APPEAL:

Whether a standard appeal or an expedited appeal, we will notify you in writing of the decision. If the decision is favorable to you, we will arrange for you to get the service or payment in question as quickly as your health condition requires.

EXTERNAL APPEALS

If we do not decide in your favor for a service or payment of a service, you have additional appeal rights, called external appeal rights. Your request to file an external appeal can be made either verbally or in writing. The external appeal involves a new and impartial review of your case through either the Medicare or Medicaid program. The Medicare program contracts with an independent review organization to provide external review on appeals involving PACE organizations. This review organization is completely independent of Edenbridge PACE of West Baltimore.

The Medicaid program conducts their external appeal through the state’s fair hearing process. Until you receive the final decision, you may choose to continue to receive these services however you may have to pay for these services if the decision is not in your favor. For reviews to Medicaid, the appeal should be sent within 30 calendar days to:

Maryland Department of Health
Office of Health Services
Attention: Appeals
201 W. Preston Street, 1 st Floor
Baltimore, MD 21201

Appeal request may also be faxed to: 410-333-5154

The Maryland Department of Health will respond with a written notice telling you of the result of your Medicaid appeal. If their decision is in your favor, Edenbridge PACE of West Baltimore will provide or pay for the service in question as quickly as your health requires, but no later than 30 calendar days after the decision.

If you are enrolled in both Medicare and Medicaid, you may choose which appeals process you wish to follow – the Medicaid Fair Hearing process or Medicare’s external appeal process. If you are not sure which program applies to you, ask us. You must choose either Medicare or Medicaid. The External Appeal may only be made to one or the other, (Medicare—or– Medicaid) but not both. Edenbridge PACE of West Baltimore can help you choose which external Appeals process to pursue. You will get a decision within thirty (30) calendar days after you request the appeal.

If you are enrolled in both Medicare and Medicaid or Medicare only, and you choose to appeal using Medicare’s external appeal process, we will send your appeal to a separate review panel that Medicare has designated as the agency for reviewing external appeals. If the Medicare designated agency’s decision is in your favor, we must give you the service as quickly as your health condition requires.

If you have requested a payment for a service that you have already received, we will pay for the service.

If the Medicare designated agency’s decision or the Medicaid Fair Hearing is NOT in your favor, there are further levels of appeals, and we will assist you in pursuing your appeal further if you chose to do so.